1993-0624_CAPITAL & COUNTIES USA_Insurance Certificate /3.0.5v
AI`11I.IP„ CERTIFICA1 OF INSURANCE ISSUE DATE IMM/DD/YY)
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
.1:1 :al'1 i'r I:::+.ir is IIIc • €1I'(:) POLICIES BELOW.
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r•'• rs,
COMPANIES AFFORDING COVERAGE
COMPANY
LETTER A f.:IIl.lr:ti:. (3F•;01.1P
COMPANY B
INSURED LETTER
COMPANY RECEIVED ft�)[{�� j� 9 (�(�
c..!'.I:a::.'F r:l1 'c f..(:a+.Al'1'I:::I.(i• :i t.1.i::, .I.I'i(': a LETTER C RECEIVED �IUN 2 1993
.1. 1.'1'!1 T'I'1:!.r;l t:Y L 9 Y 'I! 2 COMPANY
94 1
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C: i .1. :I LETTER D I
COMPANY E
LETTER
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THS INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE(MM/DD/YY) DATE(MM/DD/VY)
GENERAL LIABILITY „!•<;O � � '.;?3 :! ,;11, �.' GENERAL AGGREGATE $ 0,1l, i 1 0,;i
COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ ,2000000
CLAIMS MADE X OCCUR. PERSONAL 8 ADV. INJURY $ ,I 00000(0
OWNER'S 8 CONTRACTOR'S PROT. EACH OCCURRENCE $ :1(I0O000
FIRE DAMAGE(Any one tire) $ 130000
MED.EXPENSE(Any one person) $ j 0 raj f)
AUTOMOBILE LIABILITY
COMBINED SINGLE $
ANY AUTO LIMIT
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Per accident)
GARAGE LIABILITY
PROPERTY DAMAGE $
EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION STATUTORY LIMITS
EACH ACCIDENT $
AND
DISEASE—POLICY LIMIT $
EMPLOYERS'LIABILITY `I
DISEASE—EACH EMPLOYEE $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
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F)'T'1't°,C:!"IL'i:i:+ :;t;.0i.0 F:'0R PIi:ItII'r':I:l:) 1:! ;t.I -.r :I:P•IF f:rf;i'Ir^I'i'7:0IN
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL 2SKD841K/®AXJZ
o r: 1 i 0 E i'iir N •..11..16N f::AP.!.;:i•1'I:::AN :; MAIL I'' DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
D 1:::PT 1.I T:. 1:;,N 0 • . LEFT,?EDCDC>4IA.a1AA QC JQ 29)QJFitt IN 2S Q1C&X 1(1)97.11V QS)6*IX 2GX DIGrR19E FC AMQIGI 1C74VC➢CW4><C5F1C
ASE0 t')DIE!...Fii!l'U DM)(PS0OW • :.•• •• 4 ).1 cXXX11-25 XAVOCIP PtMIC XACI AV.(
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AN CA:' .,.,:. f t-,r"+N('13. t.:PI 9.,:.c:•!:':! ,
AUTHORIZED R RESENTATIVE
ACORD 25-S (7/90) �4'* "!',ACORD CORPORATION 1990
375U/ /L I .VivriviLrt�,irL uLJ1LMHL LIHCILI I 1
THIS ENDORSE VT CHANGES THE POLICY. PLE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person or Organization:
CITY OF SAN JUAN CAPISTRANO
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the
Schedule, but only with respect to liability arising out of "your work" for that insured by or for you.
CG 20 10 11 85 Copyright, Insurance Services Office, Inc., 1984